Admission Form Admission Form Admission Form Your pet will be examined as soon as possible. Please understand that the priority in which admitted patients are examined is based on the severity of their condition. Thank you. **DUE TO OSHA SAFETY PROCEDURES, RAW FOOD IS NOT ALLOWED IN HOSPITAL** Please be aware that discharge times may be as late as 5pm-7pm. Name * Name First First Last Last Pet's name * Phone * Email * Reason for Examination * When was the last time your pet ate? * Please list any medications that your pet is taking Medication Dosage/Frequency When last dose was given plus1 Add another medication minus1 Remove a medication Has your pet ever had an adverse reaction to any medications? * Yes No If yes, please describe Please check any that apply Vomiting Diarrhea Loss of appetite Increased appetite Coughing Sneezing Weight loss Increased thirst Increased urination Change of food Table food Access to outdoors N/A Limping? * Yes No Which leg(s)? Right front Left front Right rear Left rear Wounds? * Yes No Location Authorization * I give permission for diagnostics (x-rays, bloodwork, etc.) or treatments recommended by the doctor. * I give permission for sedation/anesthesia, if necessary. * Please contact me to authorize any additional tests/treatments. To ensure the safety of all animals in our care, please be aware that if your pet is not fully vaccinated and contracts an illness while staying with us, we cannot be held responsible for any resulting medical cost. * I understand I understand that all charges must be paid in full upon discharge. An estimate will be provided for expenses anticipated to exceed $200.00. I understand that should my pet require hospitalization, I will be required to return with a deposit equaling half of the estimate. If fleas are present upon examination, we will apply a flea elimination product to your pet and the charge will be added to your invoice. Please understand that this is necessary to safeguard our hospital. Signature * signature keyboard Clear Date * Submit If you are human, leave this field blank.
